Osteoarthritis and Rheumatoid Arthritis
Osteoarthritis and rheumatoid arthritis make up over 150 diseases and syndromes which are generally progressive and associated with severe pain and disability (WHO, 2018). These conditions are generally categorised as joint diseases, spinal disorders and conditions resulting from trauma. Osteoarthritis is a local degenerative joint disease affecting one or multiple joints and most commonly in the hands, hips, spine, and knees. Rheumatoid arthritis is a chronic, systemic inflammatory disease in which there is a pathologic activity of the immune system against joint tissues. Other common rheumatic diseases include fibromyalgia, systemic lupus erythematosus, gout, and bursitis.
The joints of the human body are fundamental for movement and also support the weight of various appendages. Therefore, the health of the joints must be preserved as they are central to movement and locomotion. The structural mechanisms of the body’s joints undertake numerous deteriorating changes due to ageing and are also prone to injury, infection, disease, and other ailments that can have an adverse effect on the capability of joints to function correctly. This may lead to a reduction in movement and therefore a decrease in the individual's physical activity levels. It is important to acknowledge that physical activity offers a positive stimulus for joint health and is vital for overall health. It is therefore essential that exercise professionals are correctly informed about the pathophysiology of these joint structure disorders and understand the role exercise interventions can have regarding supporting the clients physical activity and health.
Osteoarthritis (OA) is a progressive joint disease that affects the cartilage, joint lining, ligaments, and bone. For the individual that has this condition, OA manifests to increased pain, swelling, and stiffness at the affected joint or joints site (Figure 1). The most common areas that OA affects are the hands, knees, hips and spine all of which lead to a reduction in physical activity and ultimately increases morbidity and mortality (Nuesch et al., 2011). Osteoarthritis is the most common form of peripheral joint arthritis and cause of disability in the UK. It is a chronic musculoskeletal disorder categorised by the involvement of all joint structures including the synovial membrane, cartilage and bone.
In the UK approximately 8.5 million people have painful joints attributed to OA. Osteoarthritis is more common in females and people in older age groups; X-ray studies have shown that at least 50% of people older than 65 have signs of OA. Comorbidities including obesity further increase this risk factor. This, along with the ageing population, is adding to the increasing number of individuals with osteoarthritis. The total cost to the UK economy is approximately 1% of the annual gross national product. For example, in 1999/2000, 36 million working days were lost due to OA, costing the UK economy almost £3.2 billion in lost production.
Figure 1. Health joint vs osteoarthritic joint
Overview of the Pathophysiology of Osteoarthritis
Osteoarthritis has been defined by the American Academy of Orthopedic Surgeons (AAOS, 2007) as quantifiable joint deterioration by DXA or x-ray, signs of deterioration, or a combination of both. We should acknowledge that OA causes progressive degeneration of cartilage and causal bone changes that result in issues with bone articulation.
The typical signs of OA begin at 40 years of age and escalate in severity and range with ageing (Litwic et al., 2013). Unfortunately, the exact cause(s) of OA is unknown, and while a genetic link has been suggested, other risk factors for OA development have been suggested (Prieto-Alhambra et al., 2014). These risk factors include sex, age, race, excess body mass, previous joint trauma, a physically challenging profession, structural misalignment, muscle weakness, and oestrogen deficiency. The development of the disease can be induced by inadequate loading patterns that place cyclic stress on areas of the joint cartilage and connected structures that are sub-optimally suitable to adapt to such loads (Vincent et al., 2012). It is important to consider these risk factors as OA is classified by its aetiology and is commonly considered as idiopathic localised, idiopathic general, or secondary osteoarthritis (i.e. associated with known trauma, neuropathic, or other identifiable medical condition).
Effects of Exercise and Recommendations for Clients With Osteoarthritis
Those individuals with OA and are overweight or obese can benefit from exercise-induced weight loss as this reduces stress imposed on the weight-bearing joints (Latham and Liu, 2010). Additionally, Anwer and Alghadir, (2014) suggested that physical activity and exercise may also increase joint stability, muscle strength, coordination, balance, proprioception, and joint mobility.
Exercise program design recommendations for individuals with OA are summarised in Table 1. The American College of Rheumatology advises that individuals with OA engage in resistance, aerobic and range of motion exercise.
Resistance training should be performed two or three times per week at a moderate intensity level for six to eight repetitions and two or three sets per exercise, in a progressive overload manner is suggested (American Geriatrics Society Panel on Exercise and Osteoarthritis, 2001).
Aerobic exercise that improves large muscle groups such as swimming, cycling, or walking should be performed three to five days per week at a light to moderate intensity (i.e., 55 to <75% maximal heart rate [MHR] or an RPE of 9 to 13) for 20 to 30 minutes (American Geriatrics Society Panel on Exercise and Osteoarthritis, 2001).
Exercise to increase the individual's flexibility and mobility should be introduced three to seven days per week, with three sets of one to five repetitions per muscle group, and held for 5 to 30 seconds, depending on the individual's initial flexibility levels.
Table 1. NSCA Exercise Program Design Recommendations for Clients With Osteoarthritis
Rheumatoid arthritis (RA) is an autoimmune disorder that causes chronic inflammation of the joints of the body (Tuna et al., 2015). The possibility of developing RA is less than 5% for either sex, though it is greater for females than males (Crowson et al., 2011). Rheumatoid arthritis normally affects individuals over 40 years of age but can develop earlier. The lasting effects of RA are atrophy of muscles (Strasser et al., 2011), joint deformity, and disability (Aviña-Zubieta et al., 2008). This incapacity results in a continuing decline in physical mobility and quality of life and premature death (Jahanbin et al., 2014). As an autoimmune disorder, RA is associated to other serious diseases, such as cardiovascular disease, anaemia, lupus, interstitial lung disease, Sjogren's syndrome, vasculitis, osteoporosis, and reduced kidney function (Hallowell and Horton, 2014; Cheungpasitporn et al., 2004; van Breukelen-van der Stoep et al., 2015). People with RA are also at an increased risk for falls and osteoporosis. Also, there are several psychosocial issues related to RA including depression, reduction in quality of life, work disability (van Vilsteren et al., 2015), decreased self-efficacy, and alterations in lifestyle and environment.
Pathophysiology of Rheumatoid Arthritis
Rheumatoid arthritis is the most common autoimmune disease (Verhoeven et al., 2016) found worldwide. RA typically occurs in people with descendants from Asia or Europe (Helmick et al., 2008) and family history has also been acknowledged as a risk factor for this disease. This disorder manifests more commonly in women (Jahanbin et al., 2014) and in smokers (Wasserman, 2011) affecting 1% globally (Ovayolu, Ovayolu and Karadag, 2011). Intriguingly, Kaaja and Greer (2008) reported that pregnancy may trigger remission of the disease and there is a reduced risk of disease development in females who breast-feed their children. Furthermore, Zhang et al., (2017) suggested that there is a strong association between low socioeconomic standing, lower education attainment and pain perception in individuals with RA. Hashimoto et al., (2015) noted that many individuals with RA are inactive. The authors examined 20 RA subject’s physical activity levels (via a wrist accelerometer [actigraph]) and in healthy individuals. Hashimoto and colleagues reported that the mean activity count was significantly lower, and the low activity ratio was greater in RA subjects compared to healthy subjects.
The body’s typical protective response against foreign elements is that of inflammation. However, in the case of RA, the body’s immune system releases antibodies that cause inflammation that attacks the cartilage and synovial lining of the joints. The synovia provides a protective deposit for the joint and tendon. As the inflammation advances, it causes coagulation of the joint lining and the joint becomes disproportionately filled with synovial fluid. The wrists, hands and fingers are typically affected with RA individuals reporting pain, stiffness and localised inflammation of the joints. The inflammation and swelling may cause lumps or rheumatoid nodules underneath the skin and also joint deformity. Jones and colleagues (2015) stated that the systematic joint damage and increased disability caused by RA typically advances over 10-to-20 years. During RA advancement the inflammation extends to other systems that damage tissue including the lining of the lungs and the heart as well as vessels connected with other organs including the kidneys (Hallowell and Horton, 2014).
Figure 2 . Rheumatoid arthritis can cause pain, swelling and deformity. As the tissue that lines your joints thicken, fluid builds up leading to joint erosion and degradation.
Wasserman (2011) characterised RA as patients with elevated blood pressure, fever, inability to maintain body mass and unknown fatigue. A joint working group from the American College of Rheumatology and the European League Against Rheumatism in 2010 developed a new classification criterion for RA (Aletaha et al., 2010). The key purpose concentrated on: (1) the identification among patients with newly presented homogenous inflammatory synovitis; (2) factors that best categorise between those who were and those who were not at high risk for persistent erosive disease. The new criteria the working group set as “definite RA “is founded on the confirmed presence of synovitis in at least one joint and the absence of an alternative diagnosis the better describes the synovitis. Patients with a total score of >6 (out of 10) from the specific scores in four areas including (1) number and site of involved joints (score range 0–5); (2) serologic abnormality (score range 0–3); (3) elevated acute‐phase response (score range 0–1); and (4) symptom duration (2 levels; range 0–1).
Unfortunately, at this stage, there is no known treatment to regulate the inflammation caused by RA. Through careful control and management of the individual’s joint inflammation, the pain associated with RA can be reduced (Furst and Emery, 2014). As a result of this management, the individual can maintain their physical activity levels and health status, decreasing the potential for chronic complications associated with RA (Davis and Matteson, 2012).
Effects of Exercise and Rheumatoid Arthritis
When prescribing exercise to an RA client they must meet the minimum inclusion criteria for healthy adult populations (Chang et al., 2003). Talbot and Smith (1975) previously noted that individuals with RA that do not engage in regular exercise will experience the same effects of a sedentary lifestyle observed in healthy individuals. Engagement in regular cardiovascular training may aid in the reduction of associated health risks of CVD, obesity and diabetes. Furthermore, it has been suggested that performing moderate-intensity aerobic exercise (65-to-<75% MHR) can be beneficial for people with RA. Additionally, Strasser and colleagues (2011) reported that resistance training (RT) can help reduce RA related muscle atrophy and ensuing strength loss that can lead to osteoporosis and recurrent falls. Several studies have investigated RT in subjects with RA and reported encouraging results (Breedland et al., 2011; Strasser et al., 2011).
Breedland and colleagues (2011) investigated the effects of group-based exercise and educational program on physical performance and disease self-management of individuals with RA. Thirty-four patients diagnosed with RA participated in the randomised control study for 8 weeks. The intervention consisted of physical exercise designed to increase aerobic capacity and muscle strength (force-generating capacity) with an educational program to improve health status and self-efficacy for disease-self-management. The results demonstrated that the intervention group reported significant improvement (12.1%) in VO2max at week 9 compared with the control group (-1.7%). While significant within-group changes were observed over time for upper and lower extremity muscle strength and health status that favoured the intervention group, no between-group changes were found regarding these outcomes.
Strasser and colleagues (2011) examined the effects of combined strength and cardiovascular training (CT) on RA disease activity and functional ability. Forty RA patients (aged 41-73 yrs) were randomly assigned to a 6-month supervised CT program or a control group. The intervention group consisted of strength training including sets of weight-bearing exercises for all major muscle groups. In addition to strength training, regular cardiovascular endurance training was performed on a cycle ergometer two times per week. The authors reported that RA patients involved in CT intervention that disease activity (p = 0.06) and pain (p = 0.05) were reduced after the 6-month training intervention period while general health (p = 0.04) and functional ability (p = 0.06) improved. Cardio-respiratory endurance improved significantly (by 10%) after 6 months of CT (p < 0.001). The overall muscular strength of RA patients undertaking CT increased by a mean of 14%. Lean body mass increased, and the percentage of body fat decreased significantly (p < 0.05).
The training programs for individuals with RA examined by Strasser et al., (2011) and Breedland et al., (2011) were programs that used both resistance training and cardiovascular training. Both training interventions were comparatively short (eight weeks and six months, respectively). Cycle ergometry was initiated at 60% heart rate reserve for 40 minutes twice a week. The Breedland et al., (2011) study integrated an educational element in addition to the physical training, teaching self-management techniques to aid individuals in their disease managing. Research has also reported positive effects on balance and range of motion from other types of training such as yoga (Evans et al., 2011) and tai chi (Han et al., 2004). The exercise professional must consider how the clients perceive the benefits of exercise and their limitations, the environment, and barriers to exercise (Verhoeven et al., 2016).
Current Exercise Recommendations for Clients with Rheumatoid Arthritis
Exercise program design recommendations for clients with RA are summarised in Table 2. Exercise professionals must consider several areas including the client’s interests, physical fitness levels, classification of RA, current and acute pain levels, and goals when prescribing an exercise intervention. It is recommended that the warm-up should consist of dynamic activities that are performed at a light to moderate intensity. For individuals with a high rheumatism classification or those experiencing inflammation or pain, it is suggested that no-impact or limited impact activities to large muscle groups should be encouraged. These physical activities include walking, swimming, cycling, elliptical or rowing machines, or water-based (e.g., water aerobics and water walking or deep water running).
Individuals with RA should initially perform light to moderate level exercise and advance to moderate- to high-intensity aerobic activities. If the RA client can tolerate running and sport then they should perform two to five days per week at an intensity of 55-to-85% MHR (Breedland et al., 2011; van den Ende et al., 2000; Zippenfening et al., 2014). Additionally, the RA client should be encouraged to perform RT to strengthen all major muscle groups at a loading of 40-80% 1RM two-to-three days per week eventually progressing initially from one-to-two sets to three to four sets of 10-15 repetitions. Furthermore, a combination of intermittent aerobic exercise and RT at an intensity that is tolerated can be suggested. Exercise professionals should consider the main joints affected by the RA and alter activities accordingly. Balance and range of motion from other types of physical training (i.e., yoga, tai chi, and stretching) should also be encouraged. It is also imperative that the client’s pain levels are monitored, and exercise is adjusted accordingly. The cooldown should comprise of five-to-10 minutes of light-intensity aerobic activity and static stretching.
Table 2. NSCA Exercise Recommendations for Clients with Rheumatoid Arthritis